This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Ravenswood Therapy Group and its therapists are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices of Ravenswood Therapy Group, you may contact your therapist at 773.334.6160.

Effective date of this notice: April 14, 2003

Use and Disclosure of Protected Health Information

In order to provide you with effective care, there are times when therapists of Ravenswood Therapy Group will need to share your Protected Health Information (PHI) with others, with your written authorization. These times include:

1. Treatment: We may use or disclose your PHI to provide, coordinate, or manage your health care or any related services. An example of treatment would be when we consult with another health care provider, such as your physician, another psychotherapist, or a psychiatrist.
2. Payment: We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. We may disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. We also have the right to verify that the payment information you are providing is accurate.
3. Regular Health Care Operations: We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing) provided we have a written contract with businesses that require it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
4. Required By Law: Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the Department of the Privacy Rule.
5. Communication: To provide continuity of care, we may contact you and have communication with you or other treatment providers, share your PHI, via the following modes: telephone, email, text messaging, voicemail, internet video conferencing.

Information Disclosed Without Your Consent

Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances:

1. Serious Threat to Health or Safety: If you communicate to Ravenswood Therapy Group a specific threat of imminent harm against you or another individual, or if we have reason to believe that there is a clear, imminent risk of physical or mental injury being inflicted on you or another individual, we may make disclosures that we believe are necessary to protect you or that individual from harm.
2. As Required by Law: We may disclose information about you when required to do so by federal, state, or local laws and statutes, such as when mandated by a court order or if we have reason to believe that there is abuse or neglect to a child or elder.
3. Health Oversight Activities: We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.
4. Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding.
5. Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes. If a crime is committed on our premises or to personnel, we may share information with law enforcement to apprehend the criminal.
6. Appointment Reminders: We may contact you via various communication modes to provide appointment reminders or to obtain feedback regarding services and resources provided.
7. Change of Ownership: In the event Ravenswood Therapy Group is sold or merged with another organization your health information will become the property of the new owner.
8. Coroners: We are required to disclose information about the circumstances of a client death to an investigating coroner.
9. Workers’ Compensation: We may disclose PHI about you to comply with laws relating to workers’ compensation or other similar programs that are established by law and provide benefits for work-related injuries or illness without regard to fault.

Your Health Information Rights

1. Right to Inspect and Copy Record: You are entitled to inspect and/or obtain a copy of your health information, with limited exceptions. Your request must be in writing. If you request a copy of the information, we may charge a reasonable fee for this service.
2. Right to Release of Record: You may consent in writing to the release of your record to others, for any purpose you choose. This could include authorization to your attorney, employer, or others that you wish to have knowledge of your care.
3. Right to Restriction of Record: You have the right to request restrictions on certain uses or disclosures of your health information. Such a request should be made in writing to your therapist. We are not required to agree to your request if we believe that it is in your best 2 3 interest to permit use and disclosure of this information. If we agree, we will abide by our agreement unless the information is needed in an emergency or by law.
4. Right to Amend Record: You have the right to request and amend your PHI for as long as the PHI is maintained in your record. We may deny your request. If we deny your request, you have a right to file a statement that you disagree with the record. This statement will be added to your record.
5. Right to Receive Confidential Communication by Alternate Means and at Alternate Locations: You may request that we send information to another address or by alternative means, for example contacting you only by mail or at work. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide information about your health. We will honor your request as long as it is reasonable.
6. Right to an Accounting of Disclosures: You may request an accounting of any disclosures we have made related to your PHI, except for information used for treatment, payment, or health care operations or information that we shared with you or for which you gave authorization to disclose. This accounting also excludes information we are required to disclose by law. To request an accounting of disclosures, you must submit your request in writing. Such accountings are available for disclosures beginning April 14, 2003, and remain available for six years after the last date of service. We will notify you of any cost involved in preparing this list.
7. Right to Obtain a Paper Copy of this Notice: You have the right to receive a paper copy of this notice and any amended notice upon request. Copies are available from your therapist and on our website, www.ravenswoodtherapygroup.com.

   Right to Revoke This Consent: You may revoke this consent in writing at any time, but only to the extent that we have not taken action based upon your prior authorization, you have the right to inspect and copy your health information.

Changes to this Notice of Privacy Practices

Ravenswood Therapy Group and its therapists reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such an amendment is made, Ravenswood Therapy Group is required by law to comply with this notice.

Complaints

If you believe that Ravenswood Therapy Group has violated your privacy rights you may file a written complaint with us or with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington D.C., 20201 or by calling 202.619.0257. We will not retaliate in any way against you for filing a complaint.